Muslims in the United States

Muslim immigrants have been a small but consistent presence in the United States since colonial times. Arriving first as slaves primarily from West Africa (Gomez, 1994), Muslim immigrants began to arrive voluntarily from several Near-Eastern and Central Asian countries in the early 20^th century (Nyang, 1999; Wormser, 2002). The number of Muslim immigrants to the United States increased during the cold war years and continued growth has been noted as a result of regional conflicts (Coughlan & Owens-Manley, 2005; Ratliff, 1997). Births and conversions have also consistently contributed to the population over the last century (Pew, 2007). Muslims are therefore a diverse and persistent part of America’s immigrant ancestry.

The number of Muslims in the United Sates is unclear with estimates ranging from 2 to 11 million people (Haddad, 2004; Stone, 1991). Most researchers agree that the population growth is significant and continues to grow rapidly due to immigration, conversion, and births. The population is also increasingly diverse, with a little more than half identifying as foreign-born immigrants (Pew, 2007) from over 50 different countries. Of those who are native-born, 20% identified themselves as African-American and 15% as belonging to an ethnicity other than African-American. Twenty-one percent of the native-born Muslims identified themselves as converts to Islam, and 14% stated that they were born Muslim (Pew, 2007, p. 7).

Conceptions of Mental Illness in the United States

Lay conceptions of mental illness in the United States, particularly related to the cause of mental illness, tend to differ dramatically from the accepted definitions within the clinical community. For example, the lay population may interpret a DSM-defined mental disorder as God’s will (Link et al., 1999; Wesselmann & Graziano, 2010), a sign of weakness Schnittker, Freese & Powell, 2000), or a result of upbringing (Kuppin & Carpiano, 2006). Many lay definitions tend to be broader, and exclude many symptoms used in the diagnostic manual (Granello & Granello, 2000; Harland et al., 2009; Pescosolido et al, 2000; Link, Phelan, Beshnahan, Stueve, & Pescosolido, 1999; Kuppin & Carpiano; 2006). Given a lack of agreement among mental health professionals and between professionals and lay people regarding what is and what causes mental illness, there continues to be a discrepancy in understanding what constitutes a mental illness in American society.

Islamic Conceptions of Mental Illness

Historical Islamic conceptions of mental illness can be divided into three categories: (a) theoretical concepts developed by Islamic philosophers, religious leaders, and scholars; (b) theologically derived positions based upon the Qur’an and prophetic traditions (the latter category called both sunnah and hadith); and (c) the lay beliefs of individuals and groups in traditional Muslim societies. These beliefs include definitions of mental illness, causes, and predictors of mental illness that are commonly found within traditional Muslim societies, classification of symptoms, and proscribed treatment methods.

The traditional Islamic conception of mental illness asserts that all mental and behavioral dysfunction has a psycho-spiritual root and can be directly tied to an individual’s higher spiritual awareness of his or her Creator (Athar, 1993; Husain, 2006; Shafii, 1988; Haque 2004. An explanation of what constitutes dysfunction is elusive, and has changed over time depending upon the cultural and social contexts. “Sickness of the Heart” or “Diseases of the Heart” (in Arabic amrad al-qalb) are terms generally used in Islam to describe illnesses of a psycho-spiritual nature. Due to core beliefs in predestination and the transcendent and omnipotent nature of God, Muslims also tend to view psychological disorders as a test from God, God’s will, and a form of punishment for sin (Husain, 1998).

Islamic tradition also recognizes supernatural connections to mental illness. Prophetic traditions record various incidents that involve jinn, evil eye, and black magic (El-Zein, 2009) and in several traditions, it is recorded that he recited particular prayers to ward off evil jinn and black magic. The presence of these narratives has been, and continues to be, the legitimizing factor for supernatural causes of mental illness. Severe symptoms of psychopathology, including hallucinations, nightmares, extreme lethargy, and physical symptoms with no known physical causes are often attributed to Jinn possession in Muslim majority countries (Husain, 1998; Speziale, 2003). The Qur’an and hadith identify the jinn as spirit entities capable of appearing in different forms, and of acting in a beneficent or harmful manner toward humankind (Ameen, 1992). The attribution of mental illness to possession by jinn has been documented in contemporary Muslim populations in South Asia, South Africa, and the Arab world (Al-Adawi et al., 2002; Al-Issa, 2000; Ally & Laher, 2008).

The idea of the evil eye reflects similar conceptions that mental illness can be caused by external, supernatural forces Affliction with the evil eye is said to occur when a person looks or speaks with envy of another person, or when an individual fails to acknowledge God after a compliment. An example would be telling a parent how beautiful their child is, without following this statement with Mashallah (God has willed it). Bali (2004) discusses the prophetic traditions related to the evil eye: “According to Ibn Hajar [a medieval Islamic scholar], the evil eye is a glance combined with jealousy that comes from a despicable person to affect another” (p. 180). Abu-Rabia (2005) discusses belief in the evil eye among the Bedouin tribes and states: “Belief in the evil eye is constantly present in people’s lives, alongside beliefs about spirits, jinns and other demons, and it has serious implications for how individuals perceive the world and their place in it” (p. 241).

Interpretations of the cause of mental illness as a combination of both supernatural and social factors has been found by researchers in Southeast Asia (Azhar & Varma, 2000; Haque, 2010), Gulf nations (El-Islam, 2000), North Africa (Endrawes, O’Brien, & Wilkes, 2007; Fadlalla, 2005; Stein, 2000), and Pakistan (Mubbashar, 2000; Saeed, Gater, Hussain, & Mubbashar, 2000). Many of these researchers also note the continued presence of belief in mental illness as a direct result of the evil eye, God’s will, or God’s punishment in Muslim countries and in Muslim immigrant and refugee populations in the United States (El-Islam, 1982; Fadlalla, 2005; Haque, 2010; Kemp, 2007; Martin, 2009). These beliefs seem to be moderated by factors such as level of education and exposure to contemporary Western concepts of psychopathology.

The traditional Islamic psycho-spiritual understandings of mental illness bear little resemblance to modern day problems that are categorized in contemporary Western texts as mental illness. However, the “states” of illness that are described in traditional Islamic texts, often led to symptoms that many of us recognize today, such as obsessions, anxiety, depression, delusions, hallucinations, and hypochondria (Alawi, 1992; Al-Issa, 2000; Husain, 2006; Shafii, 1988). Historically, Muslims viewed these symptoms as having originated from a lack of faith or immoral behavior. The findings of contemporary research studies on mental illness in predominantly Muslim countries continue to support a multidimensional model of understanding mental illness as having supernatural, social, and biological causes. No one model of mental illness is accepted within the various populations, and, in many cases, the supernatural model continues to dominate (see Farooqi, 2006; Abu-Rabia, 2005; Endrawes, O’Brien & Wilkes, 2007; Johnsdotter, Ingvarsdotter, Ostman, & Carlbom, 2011, Haque, 2008).

The idea that multiple explanations for the cause of mental illness can coexist in contemporary Muslim thought may be confounding to those outside the tradition. Muslims, particularly religious leaders, traditional healers, and individuals who are unexposed to Western medical modalities, believe that spiritual and social causes of mental illness are as likely as any physical cause. The beliefs and attitudes of religious leaders in the Muslim world reflect, to a certain degree, the beliefs held by many contemporary Muslims living in traditional Islamic societies. What is not understood, however, is the degree to which these beliefs are carried over into the United States, or embraced by American-born Muslims. This study seeks to understand how, if at all, traditional Islamic conceptions of mental illness manifest within the American Muslim population.

Survey Instrument

The survey instrument utilized here has been designed by the author to compensate for the lack of an available instrument that incorporates traditional Islamic conceptions of mental illness outlined in the review of the literature, and that has been tested in previous research for reliability and validity. The survey has been designed to be easy to understand and straightforward. An anonymous survey format was chosen for this study because of stigma related to the topic and a general suspicion of research and researchers that is has been found to be prevalent in the Muslim American population by previous researchers (Amer et al., 2008; Williamson & Ahmad, 2007; Rippy & Newman, 2008). The research instrument consists of three sections. The first set of questions centered on demographic information. The Conceptions of Mental Illness scale was designed by examining dozens of existing questionnaires that focus on causes, beliefs, and attitudes toward mental illness. Additional questions were designed to address culturally specific causes and beliefs that are found in Islamic theological descriptions of illness. These were derived from existing research conducted in Muslim-majority countries. The questionnaire uses straightforward statements and a Likert scale response system. Participants indicate their level of agreement with each statement. The instrument was tested with a population of 55 participants who were encouraged to provide feedback. The feedback received from participants was incorporated in order to improve overall survey design, reduce confusion, and avoid ambiguity. An exploratory factor analysis was conducted on the Conceptions of Mental Illness portion of the survey. The factor analysis using maximum likelihood and Varimax orthogonal transformation matrix factor rotation produced three factors with eigenvalues greater than 1.0. The conceptions of mental illness questions were divided into three subscales based on the results of the exploratory factor analysis. These subscales represent three separate conceptions: 1) Western biomedical conceptions, 2) traditional Islamic conceptions, and 3) spiritual conceptions (mental illness as a test from God or the Will of God). The third part of the survey consisted of two open-ended questions which allowed participants to address their own definitions of mental illness and additional causes of mental illness not included in the close-ended portion. Data was analyzed using SPSS version 16.0.

Procedures

Prior to data collection, institutional review board approval was obtained. All potential participants were provided a brief description of the study via either a paper or electronic “cover letter” that informed them of the purpose of the study, potential benefits and risks of participation, and the voluntary nature of their participation. Surveys were distributed to Muslim Americans through both paper distribution and online distribution. The methods of distribution were chosen in order to increase response rates and reach a more diverse segment of the Muslim American population than could be achieved by one method alone. A multi-modal sampling method has been determined to be the best method of survey distribution within the Muslim American population, based on previous large-scale studies (conducted by the Pew Research Center and the Council on American-Islamic Relations (CAIR)), and smaller studies (Aloud & Rathur, 2009; Rippy & Newman, 2006).

The method of paper survey distribution was through religiously based organizations and mosques, located primarily in the Southeast region of the United States. Packets included the cover letter and full survey, and were enclosed in brown envelopes. A designated place for completed surveys to be dropped off on-site was determined by the mosque or Islamic center leader, and announced to the congregation.

A second method used to disseminate the survey was through the Internet. The online survey site SurveyMonkey was utilized to provide the survey anonymously to web users. The online survey was distributed by advertising on the social-networking site Facebook, sending the cover letter with a link to the survey to the listservs of Muslim organizations, and through individual emails to Muslim community leaders who were asked to disseminate the survey to friends, colleagues, and community members. The SurveyMonkey link was available for four months. This method of survey distribution relied on the power of snowball sampling to increase response rates across a diverse and geographically diffused population.

Participants

The 255 participants (118 males, 136 females, 1 unidentified) ranged in age from 18 to 98 years old (M = 36.1, SD = 15.6). Reported marital statuses were single (29%), married (62.7%), widowed (0.8%), divorced (4.7%), and engaged (2.7%). Participants’ self-reported race or ethnicity was categorized into eight groups: Caucasian/White (13%), Asian, including South, South East, and Asian Indian (44.5%), Mixed or Multi-Racial (5.9%), Middle Eastern/Arab (15.5%), African American/Black (11.3%), Native American/American Indian (0.8%), Hispanic/Latino (1.3%), and Other (7.5%).

Nine educational levels were represented among the respondents (0.8% less than high school, 17.2% High school, 10% Associates degree, 32.4% Bachelors degree, 20.8% Masters degree, 5.6% Doctorate, 1.2% each J.D. and M.D., respectively, and 0.8% other). The remaining 10% did not report their educational level. Forty-two percent of participants were born in the United States, with the remaining 58% representing 34 different countries of origin.

Years in the United States ranged from 1 to 35 years (M = 17.2, SD = 10.9) for immigrants. At the time of the study, 58% of participants reported being employed. Participants were asked to report their region of residence in the United States in order to assess distribution of the survey. As a result of paper distribution in the Southeast, 50.8% reported residing in that region. The remaining respondents stated their region of residence as 15.5% the Midwest, 12.3% as the Northeast, 1.2% as the Rocky Mountain Region, 3.6% as the Mid-Atlantic, 8.7% as the Southwest, and 7.9% as the West Coast.

Forty-one participants (16.5%) identified themselves as converts/reverts to Islam. The number of years since conversion ranged from 1 to 57 years (M = 16.6, SD = 13.2). Of the 255 participants, 252 answered questions regarding religious orientation. The majority (58.3%) identified as Sunni, 31.3% as “Just Muslim,” 2% as Shia, 0.4% as Bohra, 1.6% as Ismaili, 0.4% as Salafi, 5.6% as Sufi, and 0.4% as Wahhabi. Participants were also asked to report their level of religious practice, with 61% identifying their level of practice as “moderate,” 18.7% as “orthodox,” 10.8% as “liberal,” 8.3% as a “very strict practitioner”, 0.8% as “non-practicing,” and 0.4% as “other.”

Conceptions of Mental Illness

Responses to the conceptions of mental illness questions (see Table 1) reflect a general belief that mental illness is a disease, and can therefore be perceived in a way similar to physical disease. Participants were most likely to attribute mental illness to environmental factors such as stress, trauma, poor living environments, and family stressors, as well as behavioral risk factors such as alcohol and drug use.

A majority of participants agreed or strongly agreed that mental illness is caused by chemical imbalances in the brain. In addition, a significant percentage agreed that mental illness should be viewed from a fatalistic perspective, as both the Will of God and a test from God. Fewer percentages agreed that mental illness is caused by supernatural factors such as jinn possession, the evil eye, and black magic. Less than half agreed that mental illness results from a lack of will power, and only 14% agreed that sinful thoughts and actions cause mental illness. Non-immigrants actually had a higher level of agreement with jinn possession, the evil eye, and black magic as causes of mental illness than immigrants when the data was divided by immigrant status.

On the traditional Islamic conceptions scale (see Figure 1), actual scores fell into the scale range from 4 to 20. The mean score was 8.8 (SD = 4.94). Of the respondents, 34.1% had scores in the low range of agreement with traditional Islamic conceptions, 4.7% had high scores, and 45.8% had moderate scores reflecting moderate agreement with these conceptions of the causes of mental illness.

The results of the Western conceptions (see Figure 2) shows that scores ranged from 8 to 32, with a mean score of 17.9 (SD = 8.44). Although 8.4% of participants scored in the low range of agreement with Western conception, and 10.7% had a score in the high agreement range with Western conceptions, the majority, 65.7%, had a score in the moderate range.

The spiritual conceptions scale (Figure 3) consisted of only two questions. Scores ranged from 2 to 10 with a mean score of 3.82 (SD = 2.56). The majority of participants, 41.1%, had a moderate score, 29.8% had a high score, and 12.5% had a low score. The remaining percentage (16.6%) failed to answer the two questions on the scale.

Figure 1. Islamic Conceptions of Mental Illness Subscale - Score distributions

Figure 2. Western Conceptions of Mental Illness Subscale – Score Distribution

Figure 3. Spiritual Conceptions of Mental Illness Subscale - Score Distribution

Analysis of Open-Ended Responses

Responses to open-ended questions reveal a wide range of definitions for mental illness, with only a few respondents mentioning Islam, religion, or spirituality-related terms in their definitions. The majority of participants defined mental illness using concepts and terms that reflect mental illness as a physical, cognitive, or socio-cultural-based problem. In addition, participants identified several causes of mental illness not discussed in the close-ended statements.

Of the 255 participants, 190 (about 75%)responded to an open-ended question asking them to offer their definitions of mental illness. Definitions were analyzed using thematic analysis resulting in three dominant themes: mental illness defined primarily as (a) biomedical (b) psycho-spiritual, or (c) multidimensional. Other themes emerged that, upon further analysis, lacked saliency or could fit within one of these larger themes. Each response was placed into only one category based on keywords such as “disease,” “mind,” “deviation,” and “judgment.” Responses were initially broken down into 19 categories. Categories with the least number of responses were re-analyzed to see if they would fit into a larger, broader category. These were narrowed into eight larger, broader categories that encompass the themes of biological, cognitive, deviance, dysfunction, Islamic, multidimensional, specific disorders, and unspecified. These were further condensed into five themes: (a) mental illness defined primarily as physical, (b) cognitive, (c) mental illness as a form of deviance, (d) dysfunction or disability, and (e) mental illness as multidimensional. Upon further analysis it is clear that the bulk of responses correspond to the Western biomedical idea of mental illness, a psycho-spiritual definition typical of tradition Islamic conceptions, or a multidimensional model that encompasses biomedical, social, and sometimes spiritual conceptions.

Within the definition of mental illness as a physical or medical condition, the most common theme that emerged was mental illness as a dysfunction within the brain or a chemical imbalance in the brain; this theme was expressed in 46 of the responses. An example of this definition is: “A chemical imbalance in the brain that manifests itself in mental and sometimes physical symptoms.” Twenty-nine responses focused on cognitive and emotional aspects of mental illness. These definitions often specifically referred to problems in judgment and decision-making skills, as well as an inability to think in ways that were considered “normal.” Deviance or functioning outside of the social norms was a common theme in 19 of the responses. Some defined mental illness as a state of acting outside of norms, or behaviors that are not acceptable by society. Twenty-four participants defined mental illness using more general terms thematically categorized as “dysfunction” or “impairment.”

Only three responses referred specifically to Islam when defining mental illness. One stated that mental illness is “a challenge from Allah that is a legitimate health issue.” Another attributes it to both environmental and supernatural issues: “It can be jinn possession or current situation which person [a] is going through, it can be treatable by the help of dhikr (remembrance of God), counseling, and medical doctors.” The last response with an Islamic theme is the most detailed, focusing on spiritual and moral deficits within an individual:

Of the responses, 14 reflect an integrative or multidimensional definition that refers to more than one of these other themes in its definition. These definitions of mental illness, though broader than those found in other thematic categories, reflect a less stringent categorization. The responses of many participants reveal a great deal of thought about what mental illness is or can be, as in this example:

Fourteen responses specified a disorder or symptom, including dementia, depression, anxiety, hallucinations, schizophrenia, PTSD, and bipolar disorder. 21 of the responses were too vague to be categorized or were synonyms for the term mental illness itself.

The responses to the question, “How do you define mental illness?” suggest a varied conceptualization of mental illness that may be influenced by a variety of factors such as age, gender, culture, or experience. Though generally associated in some way with the brain or the mind, mental illness is also seen as tied to environment, socially accepted norms, and ideas about what is typical functioning.

Participants were asked to report additional causes of mental illness that they thought may not have been covered in the closed-response questions. The majority of these responses fall under the category of environmental factors. These include abuse and traumatic experiences, stress, divorce, a lack of socialization, and neglect. Specifically, acculturative stress and religious or social pressure were identified as situational factors that could lead to mental illness. One participant described the role of immigration and social factors as a particularly potent cause of mental illness within the Muslim community:

Other social factors that were attributed to causing mental illness focused on interpersonal and community relationships, as in these responses: “no hope for the future, low self worth, not being accepted by the people around you, domestic violence” and “disturbed life, tragedies (death, divorce), domestic violence, loneliness, no activity.” Exposure to toxins, chemicals, prenatal disturbances, and food additives were also viewed as causes of mental illness. These causes were detailed by six respondents. One participant elaborated on what is included in this type of environmental factor:

Another dominant theme in responses to causes of mental illness is lack of faith or lack of following Islam. Participants stated that: “Lack of remembrance of Allah and practices designed to help awaken one’s self to this remembrance.” One respondent stated that the cause of mental illness is “wholeheartedly embracing and promoting various forms of sinful practices and false worship, including false doctrines which promotes concepts of Allah being other than One God will result and manifest in some degrees or forms of mental illnesses.” In addition to a lack of faith, weakness in faith was viewed as a cause, as in these examples: “Weakness of iman (faith), weak relationship with Allah,” and “Not having strong faith in Allah or true belief.”

For others, a religious explanation was viewed as inherent, but by no means in conflict with a biological or environmental cause as found in these examples: “I believe that the physical proof is the chemical imbalance but behind that is the Will of Allah,” and “Nothing occurs without the Will of the Almighty. However, there are scientific ways the Almighty works through. They could be genetic or from a traumatic experience.” The role of supernatural forces was acknowledged in many instances, though not considered the only possible origin for mental illness: “Although the existence of jinn, evil eye, and black magic are very much real and I fully believe in them, 99.9% of mental illnesses are related to genetic and/or environmental factors. Claims of black magic and jinn almost always end up as cultural superstitions.”

Many other respondents thought that the cause of mental illness cannot be determined or is multifaceted in nature, and cannot be attributed to any one cause. One participant articulated:

A combination of factors that are biological, environmental, and spiritual in nature was common in many responses. These statements have been termed multidimensional, because they integrate more than one model of mental illness. The statement of one participant best summarizes this position: “Mental illness is such a vague term that different situations can be the result actions. But I think religious pressures, religion, and biology are all connected with each other.”

Limitations

This present study has several weaknesses. First, the sample may not be representative in terms of ethnic variety, age, gender, level of education, and religious orientation because of the convenient sampling method. The method of data collection at mosques was limited in that it reached only those who are active mosque attendees, or actively engaged in Islamic organizations or events. Another weakness of this method was reaching more men than women, due to the fact that a larger number of men attend Friday prayer services. In addition, many of the respondents are young and highly educated, which may play a significant role in the outcome of the study. Second, the sample size is small. The convenience sample, in combination with the small sample size, makes it impossible to generalize the results as representing the general beliefs and attitudes of all Muslim Americans. Muslim Americans are not a monolithic population; while Muslim Americans do share a common religious heritage, they also belong to various sects and have varying level of adherence to core religious practices. In addition to a population of American-born Muslims, Muslim American immigrants originate from a variety of countries and have been in America various lengths of time. It is impossible to parse out all the variations with such a small sample size. Further research is needed to determine if attitudes and beliefs about mental health are more influenced by particular cultural contexts than common religious orientation, as has been asserted by previous research with Muslim populations in the United States (see Haque, 2004; Kemp, 2007; Kobeisy, 2004; Martin, 2009).